Adult Consent Form Survey

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* 4. Which of the following options most closely aligns with your gender?

Woman

Man

Non-binary

A gender not listed here

Prefer not to answer

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* 5. Race/Ethnicity

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Another race

Prefer not to answer

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* 6. What is the highest level of education you have completed?

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* 7. Currently enrolled in School or Training?

Yes

Other (please specify)

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* 8. Which of the following categories best describes your employment status?

Employed, working full-time

Employed, working part-time

Not employed, looking for work

Not employed, NOT looking for work

Retired

Disabled, not able to work

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* 9. Preferred Language

English

Spanish

Other

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* 10. T-Shirt Size (for program shirts):

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* 11. Phone Number

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* 12. Alternate Phone

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* 13. Email Address

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* 14. Home Address

Section 3: Emergency Contact (Other than Parent/Guardian)

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* 15. Name

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* 16. Relationship

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* 17. Phone Number

Section 4: Medical & Health Information

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* 18. Do you require accommodations to participate fully in this program?

Yes

if Yes, (please specify)

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* 19. Do you/program participant have a medical condition we should be aware of?

Yes

If yes, (please specify)

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* 20. Allergies (food, medication, environmental):

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* 21. Medical Conditions or Special Needs:

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* 22. Doctor’s Name & Phone

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* 23. Health Insurance Provider

Section 5: Transportation & Dismissal

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* 24. How will you arrive at the program?

Walk

Bike

Public Transit

Dropped Off

Transportation provided by program

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* 25. How will you leave the program?

Walk

Bike

Public Transit

Picked Up

Transportation provided by program

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* 26. What are the goals for participating in this program?(check all that apply)

Resume building

Interview preparation

Job placement assistance

College application support

Financial aid guidance

Career exploration

Skill development (e.g., computer, trade, communication)

Behavioral Health Services

Section 6: Permissions & Acknowledgments

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* 27. By selecting all of the boxes below, I certify that I am aware and understand all that apply to the program public health surveillance data below:

Monitoring health trends and needs among youth and young adults

Evaluating program impact on physical, mental, and behavioral health outcomes

Informing service delivery, funding proposals, and community planning

Physical health (e.g., nutrition, activity, chronic conditions)

Mental health (e.g., stress, mood, coping strategies)

Behavioral health (e.g., substance use, sleep habits)

Social determinants (e.g., housing, food access, safety)

Access to care (e.g., insurance, provider visits, barriers)

Data will be aggregated and analyzed for trends; individual identities will not be disclosed

Results may be shared with funders, evaluators, and public health partners

Data will be stored securely and used only for approved program purposes

Participants may withdraw consent at any time without penalty

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* 28. This consent authorizes [2S2D] to collect, use, and disclose limited health-related information for the following purposes: (Please select that you are aware of all of these conditions)

Emergency medical response and coordination

Allergy and medication awareness

Behavioral or developmental accommodations

Communication with authorized healthcare providers (if needed)

Emergency medical conditions

Allergies and medications

Behavioral or developmental needs

Immunization status (if required by funders or partners)

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* 29. I acknowledge that I have read and aware of the following: (Please select that you are aware of all of these conditions)

Staff will supervise youth during program hours only

In case of emergency, staff will contact the emergency contact listed above

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* 30. I acknowledge that I have read and aware of the following: (Please select that you are aware of all of these conditions)

The facility is not connected to a municipal water supply

Water is sourced from an on-site private well

The well is maintained in accordance with local health department guidelines

Water testing is conducted periodically to ensure safety and compliance

Drinking water is filtered and monitored

Bottled water is available upon request

Staff are trained to respond to any water-related concerns

Parents/guardians may request water quality documentation at any time

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* 31. HIPAA Consent
All information will be stored securely and accessed only by authorized personnel. You may revoke this consent at any time in writing. Revocation will not affect disclosures made prior to revocation. You have the right to inspect and request corrections to your child’s health information.
By writing your name below, I, the undersigned parent/legal guardian, authorize [Program Name] to collect and share the above health information for the purposes stated. I understand this authorization is voluntary and may be revoked at any time.

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* 32. Revocation Rights
You have the right to revoke your consent at any time. To do so:
Submit a written request to [Insert Program Contact Name & Email] Revocation will apply to future disclosures only; it will not affect information already shared in good faith
You may request a copy of any information previously disclosed
I, the undersigned parent/legal guardian, understand and agree to the confidentiality practices outlined above. I acknowledge my right to revoke this consent at any time and understand how to do so.

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* 33. Transportation Consent
I understand that the above-named youth will be traveling to and from the afterschool program site located at 1523 Plainfield Road, Joliet, IL without a parent or guardian. I give permission for my child to:
Arrive at the program site independently by walking, biking, public transit, or other means
Depart the program site independently at the end of program hours
Be responsible for their own transportation arrangements unless otherwise communicated in writing
I acknowledge that the program is not responsible for youth once they leave the premises and that staff supervision is limited to designated program hours.

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* 34. I have received and read the Indoor Safety Protocols

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* 35. Date

Date / Time

Date

Adult Consent Form

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* 1. Full Name

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* 2. Date of Birth

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* 3. Age:

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* 4. Which of the following options most closely aligns with your gender?

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* 5. Race/Ethnicity

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* 6. What is the highest level of education you have completed?

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* 7. Currently enrolled in School or Training?

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* 8. Which of the following categories best describes your employment status?

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* 9. Preferred Language

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* 10. T-Shirt Size (for program shirts):

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* 11. Phone Number

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* 12. Alternate Phone

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* 13. Email Address

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* 14. Home Address

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* 15. Name

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* 16. Relationship

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* 17. Phone Number

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* 18. Do you require accommodations to participate fully in this program?

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* 19. Do you/program participant have a medical condition we should be aware of?

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* 20. Allergies (food, medication, environmental):

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* 21. Medical Conditions or Special Needs:

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* 22. Doctor’s Name & Phone

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* 23. Health Insurance Provider

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* 24. How will you arrive at the program?

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* 25. How will you leave the program?

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* 26. What are the goals for participating in this program?(check all that apply)

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* 27. By selecting all of the boxes below, I certify that I am aware and understand all that apply to the program public health surveillance data below:

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* 28. This consent authorizes [2S2D] to collect, use, and disclose limited health-related information for the following purposes: (Please select that you are aware of all of these conditions)

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* 29. I acknowledge that I have read and aware of the following: (Please select that you are aware of all of these conditions)

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* 30. I acknowledge that I have read and aware of the following: (Please select that you are aware of all of these conditions)

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* 34. I have received and read the Indoor Safety Protocols

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* 35. Date

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* 36. I certify that the information provided is accurate and complete. I understand and agree to the terms of participation.